Monday, February 1, 2016

Panamá City, Panama

By: Jeffrey Stambough, MD

My trip to Central America was a first for me, having never
been south of Mexico. Panamá City holds a unique place in the world primarily
because of its geography.The country
of Panamá is a large isthmus and it functions as a gateway from the Pacific to
the Atlantic, thanks in part to the development of the Panamá Canal.Although this modern marvel of sheer
engineering brings in over 5 billion dollars to the economy, this only accounts
for 6% of their GDP.The canal is
currently in the final phases of a massive expansion that will create a second,
larger channel lane to allow larger ships with more cargo to embark on the
ten-hour bypass.Needless to say, this
will further contribute to expand Panamá’s role in the global trade economy.

Hospital Santo Tomás

Panamanian healthcare in reality is a three-tiered system.Private hospitals are the desired
destination, but can be costly for the average Panamanian whose monthly wage is
around $500. There are social security
hospitals, to which all citizen’s taxes contribute, but these facilities often don’t
provide the breadth of care most people seek. Finally, there are public hospitals in the
National healthcare service (“Salud), which accept typical fee for
service.Hospital Santo Tomás (HST) is
the largest of such public hospital in the country and exemplifies this pay for
service credo. It was massively expanded in the 1920’s to it’s current 5-acre
plot and was originally called the “white elephant” for it’s grandiose size and
thought that it was too big to deal with healthcare needs.Almost, a century later, it’s a 600+ bed
hospital that routinely runs a full capacity.

I traveled with a group, Operation Walk, and we were granted access to a wing
of this hospital for a little over a week. Our group consisted of 5 surgeons, 3
anesthesia providers, 4 PAs, a collection of floor/PACU/scrub nurses, physical
therapists and volunteers to help with sterile processing, patient transport
and other tasks. We worked exclusively
at HST under the direction of our coordinating orthopaedic physician, Karla
Morales, MD, who helped recruit patients over the past year as potential
candidates for joint replacement.

Our first day in Panamá was spent conducting an
all-day screening clinic for nearly sixty patients. After a thorough pre-operative
review, we declined some people for surgery given our limited resources with
implants and/or undue surgical risk factors. As a team, we agreed upon 56
patients who we’d then perform the various knee and hip arthroplasty procedures
over the course of our week there.

Operating in a foreign country can be a daunting experience
if one fears the unknown. Will they have the necessary equipment to properly
sterilize the surgical equipment? Will there be enough modern equipment to
safely perform anesthesia? Will the rehabilitation equipment be safe? Luckily,
we quickly found the answer to these questions was a resounding yes.HST is a very advanced hospital in terms of
available resources and manpower. They have modern anesthetic monitors,
fluoroscopy (although not always someone to run it), and portable x-ray that is
nicer than most hospitals in the US! The only real problem we ran into during
our time there was that the water shut down to the sterile processor after our
3rd day of cases, so we had to all pitch in to scrub down
instruments and “flash” trays. And when we ran into issues trying to assess
preoperative leg lengths, we got creative and used books old books and journals
to act as “blocks.”

As for my interactions with the Panamanian orthopedic
doctors, there were 3-4 orthopaedic residents per class who take rotating
trauma call and are responsible for covering urgent cases.Due to the healthcare structure, however,
almost all fractures are initially managed with external fixation until the patient
can raise the funds to pay for an intramedullary nail or periarticular plate
and screws. One PGY-2 resident with whom I had the most contact, Eduardo
Camino, was extremely helpful when it came to translating during the clinical
interviews and inpatient rounds. His baseline understanding of orthopaedics
made it easy for him to navigate those waters, and in turn, made me realize
even more that knowing how to speak Spanish would have been huge advantage in
my profession.

They use the same text books that we do – Campbell’s Operative
Orthopaedics and Green’s Operative Hand Surgey – as well as read the same
journals – JBJS, Journal of
Arthroplasty, etc. Eduardo and my time together really allowed me to reflect on
all of the perks that we have not only with training in the states, but
specifically at Washington University.Our scheduled didactics would be considered a luxury in Panama, as the
students I talked with were yearning to learn the breadth of orthopaedics through
case-based learning (instead of seeing photos in a textbook).

In our time at HST, we were able to complete 48 hip and knee
replacements in 56 patients.I either
led or was directly involved with 15 of the cases.It was an eye-opening experience from
beginning to end because we saw people who had such advanced arthritic disease
that they often required substantial releases to achieve a balanced knee, for
instance. However, using the tools which we had available combined with the
perseverance of the patients, all patients were up and walking the day after
surgery. One of the physicians brought 100 vials an antifibrinolytic drug,
tranexemic acid, which was a Godsend in that in drastically cut down on the
need for post-operative blood transfusions, even though most patients started
with some baseline anemia (Hgb ~ 10) due to the rampant malnutrition in the
country.

What I will take away the most from the mission experience
was the seeing the gratitude from the individual patients from the pre-op through
the rehabilitation process. Most patients had significant dysfunction
preoperatively and had limited access to conservative treatment, such as
anti-inflammatory medications.Some
patients had fashioned a cane out a piece of wood to help offload the affected
extremity. One patient in particular made an indelible impression. The last
patient we treated was a 4’4” Franciscan nun who had advanced degeneration of
her knee.Although she was

in extreme
pain and wasn’t able to kneel for the past five years, she was extremely
vivacious and happy throughout the entire process. Every morning on rounds, she
greeted the team with a smile and hug, which turned out to be infectious in
that it served as a constant reminder of the great things that come from our
endeavors. While her surgery proved difficult given the amount of fixed
deformity and bone quality, we were able to give her a solid, stable new knee. She
was so happy she wept the day after surgery. It was a moment that I will take
with me throughout my professional career.

Participating with a group like Operation Walk provided me
insight into all the good that can come from medical mission trips. It is
definitely something that I will look to make time for as part of my
professional practice as a joint surgeon.

No comments:

Washington University Orthopaedic Surgery: Resident Travel Blog

Through the mentorship of faculty, our orthopaedic surgery residency program offers a resident trainee the opportunity to design a personalized international experience and participate in the practice of global medicine.